Trends in Trans Fatty Acids Reformulations of US Supermarket and Brand-Name Foods From 2007 Through 2011

Introduction: Although some US food manufacturers have reduced trans fatty acids (TFA) in their products, it is unknown how much TFA is being reduced, whether pace of reformulation has changed over time, or whether reformulations vary by food type or manufacturer. Methods: In 2007, we identified 360 brand-name products in major US supermarkets that contained 0.5 g TFA or more per serving. In 2008, 2010, and 2011, product labels were re-examined to determine TFA content; ingredients lists were also examined in 2011 for partially hydrogenated vegetable oils (PHVO). We assessed changes in TFA content among the 270 products sold in all years between 2007 and 2011 and conducted sensitivity analyses on the 90 products discontinued after 2007. Results: By 2011, 178 (66%) of the 270 products had reduced TFA content. Most reformulated products (146 of 178, 82%) reduced TFA to less than 0.5 g per serving, although half of these 146 still contained PHVO. Among all 270 products, mean TFA content decreased 49% between 2007 and 2011, from 1.9 to 0.9 g per serving. Yet, mean TFA reduction slowed over time, from 30.3% (2007–2008) to 12.1% (2008–2010) to 3.4% (2010–2011) (P value for trend < .001). This slowing pace was due to both fewer reformulations among TFA-containing products at start of each period and smaller TFA reductions among reformulated products. Reformulations also varied substantially by both food category and manufacturer, with some eliminating or nearly eliminating TFA and others showing no significant changes. Sensitivity analyses were similar to main findings. Conclusions: Some US products and food manufacturers have made progress in reducing TFA, but substantial variation exists by food type and by parent company, and overall progress has significantly slowed over time. Because TFA consumption is harmful even at low levels, our results emphasize the need for continued efforts toward reformulating or discontinuing foods to eliminate PHVO

Effects of Saturated Fat, Polyunsaturated Fat, Monounsaturated Fat, and Carbohydrate on Glucose-Insulin Homeostasis: A Systematic Review and Meta-analysis of Randomised Controlled Feeding Trials.

BACKGROUND: Effects of major dietary macronutrients on glucose-insulin homeostasis remain controversial and may vary by the clinical measures examined. We aimed to assess how saturated fat (SFA), monounsaturated fat (MUFA), polyunsaturated fat (PUFA), and carbohydrate affect key metrics of glucose-insulin homeostasis. METHODS AND FINDINGS: We systematically searched multiple databases (PubMed, EMBASE, OVID, BIOSIS, Web-of-Knowledge, CAB, CINAHL, Cochrane Library, SIGLE, Faculty1000) for randomised controlled feeding trials published by 26 Nov 2015 that tested effects of macronutrient intake on blood glucose, insulin, HbA1c, insulin sensitivity, and insulin secretion in adults aged ≥18 years. We excluded trials with non-isocaloric comparisons and trials providing dietary advice or supplements rather than meals. Studies were reviewed and data extracted independently in duplicate. Among 6,124 abstracts, 102 trials, including 239 diet arms and 4,220 adults, met eligibility requirements. Using multiple-treatment meta-regression, we estimated dose-response effects of isocaloric replacements between SFA, MUFA, PUFA, and carbohydrate, adjusted for protein, trans fat, and dietary fibre. Replacing 5% energy from carbohydrate with SFA had no significant effect on fasting glucose (+0.02 mmol/L, 95% CI = -0.01, +0.04; n trials = 99), but lowered fasting insulin (-1.1 pmol/L; -1.7, -0.5; n = 90). Replacing carbohydrate with MUFA lowered HbA1c (-0.09%; -0.12, -0.05; n = 23), 2 h post-challenge insulin (-20.3 pmol/L; -32.2, -8.4; n = 11), and homeostasis model assessment for insulin resistance (HOMA-IR) (-2.4%; -4.6, -0.3; n = 30). Replacing carbohydrate with PUFA significantly lowered HbA1c (-0.11%; -0.17, -0.05) and fasting insulin (-1.6 pmol/L; -2.8, -0.4). Replacing SFA with PUFA significantly lowered glucose, HbA1c, C-peptide, and HOMA. Based on gold-standard acute insulin response in ten trials, PUFA significantly improved insulin secretion capacity (+0.5 pmol/L/min; 0.2, 0.8) whether replacing carbohydrate, SFA, or even MUFA. No significant effects of any macronutrient replacements were observed for 2 h post-challenge glucose or insulin sensitivity (minimal-model index). Limitations included a small number of trials for some outcomes and potential issues of blinding, compliance, generalisability, heterogeneity due to unmeasured factors, and publication bias. CONCLUSIONS: This meta-analysis of randomised controlled feeding trials provides evidence that dietary macronutrients have diverse effects on glucose-insulin homeostasis. In comparison to carbohydrate, SFA, or MUFA, most consistent favourable effects were seen with PUFA, which was linked to improved glycaemia, insulin resistance, and insulin secretion capacity.Dr Imamura received support from the Medical Research Council Epidemiology Unit Core Support (MC_UU_12015/5). Dr Mozaffarian received funding from The National Institute of Health in the United States (R01 HL085710).This is the final version of the article. It first appeared from PLOS via http://dx.doi.org/10.1371/journal.pmed.100208

Alcohol withdrawal is associated with poorer outcome in acute ischemic stroke

To determine the association between alcohol abuse (AA) and alcohol withdrawal (AW) with acute ischemic stroke (AIS) outcomes. All adult AIS admissions in the United States from 2004 to 2014 were identified from the National Inpatient Sample (weighted n = 4,438,968). Multivariable-adjusted models were used to evaluate the association of AW with in-hospital medical complications, mortality, cost, and length of stay in patients with AIS. Of the AA admissions, 10.6% of patients, representing 0.4% of all AIS, developed AW. The prevalence of AA and AW in AIS increased by 45.2% and 40.0%, respectively, over time ( for trend 50% increased odds of urinary tract infection, pneumonia, sepsis, gastrointestinal bleeding, deep venous thrombosis, and acute renal failure compared to those without AW. Patients with AW were also 32% more likely to die during their AIS hospitalization compared to those without AW (odds ratio 1.32, 95% confidence interval 1.11-1.58). AW was associated with ≈15-day increase in length of stay and ≈$5,000 increase in hospitalization cost ( < 0.001). AW is associated with increased cost, longer hospitalizations, and higher odds of medical complications and in-hospital mortality after AIS. Proactive surveillance and management of AW may be important in improving outcomes in these patients

Abstract TP121: National Patterns of Carotid Revascularization in the Pre- and Post- Crest Era

Background: The Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) showed greater safety of carotid artery stenting (CAS) in patients (pts) 70 yo. The aim of this study was to evaluate national patterns in CAS performance in pts >70yo in the pre- (2007-2010) and post-CREST (2011-2013) era. Methods: Adults requiring CAS or CEA were identified from the 2007-2013 Nationwide Inpatient Sample (NIS) using International Classification of Disease (ICD-9) codes. We estimated the proportion of CAS performed in all age groups and used multivariate models adjusted for clinical and hospital factors to compare odds of receiving CAS in the pre- to post-CREST era. Results: We identified 839,357 weighted cases of CAS and CEA from the NIS. 15.7% of CAS and 8.4% of CEA were performed in symptomatic pts. CAS increased in all age groups over time (figure 1). Proportion of >70yo receiving CAS increased from 11.9% in the pre- to 13.9% in the post-CREST era (p=0.004). In multivariate models, odds of receiving CAS as opposed to CEA increased by 15% in all pts >70yo in the post-CREST compared to the pre-CREST period (OR 1.15, 95%CI 1.10-1.19, p70yo, while female sex (OR 0.92, 95%CI =0.89-0.97), smoking (OR 0.84, 95%CI 0.79-0.90) and weekend admission (OR 0.78, 95%CI 0.70-0.86) were negatively associated with odds of CAS. Conclusion: Rates of CAS increased in the post- compared to pre-CREST era in pts >70yo including asymptomatic women. Despite the concerns of higher periprocedural complications with CAS in elderly pts, the results of CREST have not influenced clinical revascularization practice in pts >70yo

Abstract TMP71: Increasing Prevalence of Secondary Intracerebral Hemorrhage in Acute Ischemic Stroke

Background: Temporal data on secondary intracerebral hemorrhage (SICH) risk in acute ischemic stroke (AIS) patients (pts) is sparse since implementation of current measures to lessen times to intravenous thrombolysis (tPA) and/or endovascular reperfusion. Aims: (1) Evaluate trends in SICH prevalence in AIS pts in the United States from 2004-2013 and to compare SICH risk following tPA and mechanical thrombectomy (MT) from 2011-2013 to risk in earlier periods. (2) Assess the magnitude of the current association of SICH with in-hospital morbidities and mortality in AIS. Methods: All adults with a primary diagnosis of AIS (n=4,355,140) were identified from the 2004-2013 Nationwide Inpatient Sample. We computed weighted risk of SICH in AIS according to age, sex and intervention received (tPA, MT or no-intervention). Multivariate models were used to compare SICH risks in the period 2004-2007 to periods 2008-2010 and 2011-2013, respectively, and to evaluate association of SICH with in-hospital morbidity, mortality, length-of-stay (LOS) and cost. Results: SICH risk increased over the study period but most of the increase occurred after 2010 (figure 1). From the period 2004-2007 to period 2011-2013, SICH risk increased by 75% in IV tPA pts (4.8%-8.4%), 164% in MT pts (8.1%-21.4%) and by 367.8% in no-intervention pts (0.5%-2.3%). Risks increased with age but only in tPA pts and did not vary by sex in both tPA and MT pts after multivariate adjustment. SICH was associated with >200% increased odds of ventilator use, pneumonia, sepsis, acute renal failure, deep venous thrombosis, pulmonary embolism and 67% reduced odds of home disposition compared to non-SICH. Mortality in SICH decreased from 26% to 18.3% compared to 6.1% to 4.0% in the non-SICH patients over the entire period. SICH was associated with >$8,000 increase in cost and >3-day increase in mean LOS. Conclusion: The burden of SICH in AIS is growing. Innovative strategies are needed to prevent SICH and/or alleviate its sequelae

Abstract WP354: Ten-year Temporal Trends in Medical Complications Following Acute Intracerebral Hemorrhage in the United States

Background: Data on medical complications following intracerebral hemorrhage (ICH) are sparse. We assessed trends in the prevalence of urinary tract infection (UTI), pneumonia, sepsis, deep venous thrombosis (DVT), pulmonary embolism (PE), acute renal failure (ARF) and acute myocardial infarction (AMI) following ICH in the United States and evaluated their association with in-hospital mortality (IM), cost, length-of-stay (LOS) and home disposition (HD). Methods: Adults admitted to US hospitals from 2004-2013 (n=582,736) were identified from the Nationwide Inpatient Sample. Weighted complication risks were computed by sex and by mechanical ventilation (MV) status. Multivariate models were used to evaluate trends in complication and to assess their association with IM, cost, LOS, and HD. Results: Overall risks of UTI, pneumonia, sepsis, DVT, PE, ARF and AMI following ICH were 14.8%, 7.7%, 4.1%, 2.7%, 0.7%, 8.2% and 2.0% respectively. Risks differed by sex (UTI: females (F) 19.8% vs males (M) 9.9%; ARF: M 10.6% vs F 5.9%; sepsis: M 4.8% vs F 3.4%) and by MV status (pneumonia: MV 17.7% vs non-MV 3.9%; DVT: MV 4.3% vs non-MV 3.2%). From 2004 to 2103, odds of DVT and ARF increased while odds of pneumonia, sepsis and mortality declined over time (figure 1). Each complication was associated with > 2.5-day increase in mean LOS, > $8,000 increase in cost and reduced odds of HD. ARF and AMI were associated with increased IM in all patients; sepsis and pneumonia were associated with increased IM only in non-MV patients while UTI and DVT were associated with reduced IM in all patients. Conclusion and Relevance: Despite IM reduction, ARF and DVT risk following ICH in the US have increased while odds of sepsis and pneumonia have declined over time. All complications were associated with increased cost, LOS and reduced odds of HD but their associations with IM were variable, likely due in part to survival bias. Innovative strategies are needed to prevent ICH-associated medical complications

Abstract WMP49: Temporal Trends in the Burden of Atrial Fibrillation in Acute Ischemic Stroke and Transient Ischemic Attack in the United States

Background: Large scale data on atrial fibrillation (AF) prevalence in acute ischemic stroke (AIS) is sparse since approval of dabigatran for non-valvular AF in 2010. We studied recent trends in prevalence of AF in AIS and transient ischemic attack (TIA) in the United States (US) and association of AF with in-hospital mortality, cost and length of stay (LOS) in AIS. Methods: Adults admitted to US hospitals from 2007-2012 with diagnosis of AIS (n=3,427,806) and TIA (n=502,820) were identified from the Nationwide Inpatient Sample. Weighted prevalence of AF in AIS and TIA by demographics and region was computed. Multivariate logistic regression was used to evaluate association of AF with other clinical factors and mortality in AIS. Association of AF with LOS and cost was assessed using generalized linear models. Results: AF prevalence increased by 11.5% in AIS (22%-24.5%, p80yo; TIA: 5% in 50-59yo vs 27% in >80yo), sex (AIS: 20% in M vs 25% in F); TIA: 16% in M vs 15% in F), race (AIS: whites 26% vs blacks 12%) and region (AIS: Northeast 25% vs South 21%). AF prevalence increased in all subgroups over time (p<0.001) except AIS <40yo and TIA<50yo (Figure 1). Advancing age, female sex, white race, high income, Medicare insurance, CHA 2 DS 2 -VASc score and large hospital size were associated with increased odds of AF in AIS. AF was positively associated with death (OR=1.60, 95%CI 1.56-1.64) but mortality in AIS with AF decreased from 13.2% in 2007 to 10.7% in 2012 (p<0.001). AF was associated with increased cost of $2,631 and LOS 1.1 days in AIS. Conclusion: Prevalence of AF in AIS and TIA has continued to increase. Disparity in AF prevalence in AIS and TIA exists by patient and hospital factors. AF is associated with increased mortality, LOS and hospital cost in AIS but mortality in AIS with AF is decreasing. More AIS preventive efforts are needed in AF patients especially in the elderly

Abstract Number ‐ 145: Impact of Landmark Trials on Intracranial Stenting Utilization for Intracranial Atherosclerotic Disease in the US

Introduction The Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis (SAMMPRIS) trial published in 2010 showed aggressive medical therapy is superior to percutaneous transluminal angioplasty and stenting (PTAS) for intracranial atherosclerotic disease (ICAD). Following the pivotal positive mechanical thrombectomy (MT) trials in 2015, MT utilization in the United States (US) has increased. Rescue ICAD stenting may be needed in MT patients with underlying ICAD but it remains uncertain whether PTAS use for ICAD has changed over this time. The aim of this study is to describe national trends in the utilization of PTAS for ICAD in the US before and after SAMMPRIS and following the pivotal MT trials. Methods We used a constellation of International Classification of Diseases ninth and tenth revision diagnostic/procedural codes to identify all elective and non‐elective adult (> = 18 years) ICAD admissions with or without infarction containing concomitant codes for PTAS in the 2007–2019 National Inpatient Sample. Admissions containing codes for subarachnoid hemorrhage, unruptured intracranial aneurysms or benign intracranial hypertension were excluded. We combined weighted counts of PTAS admissions with annual US adult census data to obtain prevalence of PTAS. We used joinpoint regression to evaluate trends in PTAS use over time. Results Across the study period, there were 16,477 weighted admissions for ICAD undergoing PTAS in the US. 52.4% of these admissions were in patients 60–79years and 43.2% were in women. 74.3% of these admissions were non‐elective and this proportion increased over time (P = 0.019). 26.5% of all admissions had concurrent codes for MT but this proportion increased by almost ten‐fold over time from 4.3% in 2007 to 40.0% in 2019. On join point regression, PTAS utilization increased but insignificantly from 3.0/million population in 2007 to 5.7/million population in 2010 (Annualized percentage change, APC 11.2%, 95%CI ‐11.8 to 40.3, p = 0.290), declined also insignificantly from 2010–2013 (APC ‐13.2, 95%CI ‐48.4 to 45.8, p = 0.514) and increased significantly from 3.55/million in 2013 to 3.80/million in 2014 and exponentially across the rest of the period to 8.4 cases/million in 2019 (APC 15.4, 95%CI 9.2 to 22.0, p = 0.001). Upon stratification by admission type, most of the increase across the period 2013/2014 to 2019 occurred in non‐elective admissions (Figure 1). Utilization in elective admissions varied from 0.92 to 1.96 cases per million population but this did not change significantly across the study period. Conclusions PTAS utilization for ICAD declined in the US after SAMMPRIS but has increased following publication of pivotal MT trials mainly in non‐elective admissions. PTAS utilization increased significantly following publication of pivotal MT trials likely in ICAD patients who required rescue stenting.. Additional prospective studies are needed to determine the long‐term outcomes of concurrent PTAS and MT as this is not a group of patients that was studied in SAMMPRIS

Mechanical Thrombectomy Global Access For Stroke (MT-GLASS): A Mission Thrombectomy (MT-2020 Plus) Study

Background: Despite the well-established potent benefit of mechanical thrombectomy (MT) for large vessel occlusion (LVO) stroke, access to MT has not been studied globally. We conducted a worldwide survey of countries on 6 continents to define MT access (MTA), the disparities in MTA, and its determinants on a global scale. Methods: Our survey was conducted in 75 countries through the Mission Thrombectomy 2020+ global network between November 22, 2020, and February 28, 2021. The primary end points were the current annual MTA, MT operator availability, and MT center availability. MTA was defined as the estimated proportion of patients with LVO receiving MT in a given region annually. The availability metrics were defined as ([current MT operators×50/current annual number of estimated thrombectomy-eligible LVOs]×100 = MT operator availability) and ([current MT centers×150/current annual number of estimated thrombectomy-eligible LVOs]×100= MT center availability). The metrics used optimal MT volume per operator as 50 and an optimal MT volume per center as 150. Multivariable-adjusted generalized linear models were used to evaluate factors associated with MTA. Results: We received 887 responses from 67 countries. The median global MTA was 2.79% (interquartile range, 0.70–11.74). MTA was Conclusions: Access to MT on a global level is extremely low, with enormous disparities between countries by income level. The significant determinants of MT access are the country’s per capita gross national income, prehospital LVO triage policy, and MT operator and center availability